Provider Demographics
NPI:1780244202
Name:COUCH, MACKENZIE W (MS,BCBA)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:W
Last Name:COUCH
Suffix:
Gender:M
Credentials:MS,BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SATELLITE BLVD STE 2250
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5047
Mailing Address - Country:US
Mailing Address - Phone:800-381-2195
Mailing Address - Fax:888-381-0822
Practice Address - Street 1:4500 SATELLITE BLVD STE 2250
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5047
Practice Address - Country:US
Practice Address - Phone:800-381-2195
Practice Address - Fax:888-381-0822
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-18-32004103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst